The use of direct oral anticoagulants for thromboprophylaxis or treatment of cancer-associated venous thromboembolism: a meta-analysis and review of the guidelines

Norah S Alsubaie; Shahad M Al Rammah; Reema A Alshouimi; Mohammed Y Alzahrani; Majed S Al Yami; Abdulaali R Almutairi; Osamah M Alfayez; Ghazwa B Korayem; Omar A Almohammed

doi:10.1186/s12959-021-00326-2

The use of direct oral anticoagulants for thromboprophylaxis or treatment of cancer-associated venous thromboembolism: a meta-analysis and review of the guidelines

Thromb J. 2021 Oct 30;19(1):76. doi: 10.1186/s12959-021-00326-2.

Authors

Norah S Alsubaie¹, Shahad M Al Rammah¹, Reema A Alshouimi¹, Mohammed Y Alzahrani¹, Majed S Al Yami¹, Abdulaali R Almutairi², Osamah M Alfayez³, Ghazwa B Korayem⁴, Omar A Almohammed⁵

Affiliations

¹ Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
² Saudi Food and Drug Authority, Riyadh, Saudi Arabia.
³ Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Buraydah, Saudi Arabia.
⁴ Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
⁵ Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia. oalmohammed@ksu.edu.sa.

Abstract

Background: Venous thromboembolism (VTE) is a common complication among patients with cancer and is one of the most common causes of increased morbidity and mortality. The use of direct oral anticoagulants (DOACs) for thromboprophylaxis and treatment of cancer-associated venous thromboembolism (CA-VTE) has been evaluated in several randomized clinical trials (RCTs). The aim of this meta-analysis was to assess efficacy and safety of using DOACs for thromboprophylaxis and treatment of CA-VTE and provide a summary for available guidelines' recommendations.

Methods: MEDLINE was searched to identify studies evaluating the use of DOACs for thromboprophylaxis or treatment in patients with cancer. Search was limited to peer-reviewed studies published in English. Studies were excluded if they were not RCTs or subgroup analyses of data derived from RCTs, if they did not report efficacy and safety data on patients with active cancer, or if they were published as an abstract. New VTE or VTE recurrence, and major or clinically relevant non-major bleeding (CRNMB) were used to assess the efficacy and safety, respectively. The Mantel-Haenszel random-effects model risk ratios (RRs) and the corresponding 95% confidence intervals (CIs) were calculated to estimate the pooled treatment effects of DOACs.

Results: Four studies evaluating DOACs use for thromboprophylaxis and four - for treatment of CA-VTE were included. Thromboprophylaxis with DOACs was associated with a significant reduction in the risk of symptomatic VTE (RR = 0.58; 95%CI 0.37,0.91) but with an incremental risk of major bleeding or CRNMB (RR = 1.57; 95%CI 1.10,2.26). CA-VTE treatment with DOACs was linked with a significant reduction in VTE recurrence (RR = 0.62; 95%CI 0.44,0.87) but with an incremental risk of CRNMB (RR = 1.58; 95%CI 1.11,2.24).

Conclusions: The DOACs are associated with a lower risk of symptomatic VTE and VTE recurrence, but the risk of bleeding remains a considerable concern. Clinical decisions should be made by assessing individual patient's risk of VTE and bleeding.

Keywords: Cancer; Direct oral anticoagulants; Thromboprophylaxis; Treatment; Venous thromboembolism.

Grants and funding

RSP-2020/77/King Saud University